Endoscopic diagnosis of indeterminate biliary stenosis is difficult, often requiring
repeat examinations [1]. Among rare causes of such stenoses, portal biliopathy is exceptional; 65 – 85 %
of patients with extrahepatic portal obstructions exhibit no symptoms [2]
[3]. Physiopathologically, the condition is caused by dilation of both plexuses that
return the blood of the main bile duct. This develops secondarily to portal hypertension
and compresses the common bile duct.
Here, we report the case of a 52-year-old patient with a recent history of severe
acute pancreatitis complicated by portal thrombosis and infected necrosis drained
via a lumen-apposing metal stent. During follow-up several months later, he exhibited
cholestasis in hepatic testing, and computed tomography and magnetic resonance imaging
revealed dilation of the main biliary tract but no visible obstacle, as well as a
possible distal stricture ([Fig. 1]). Endoscopic ultrasound revealed a dilated main bile duct with a thickened and edematous
wall, which was most noticeable at the level of the papilla, suggestive of an inflammatory
or tumor cause ([Fig. 2]). Doppler ultrasound showed that the hypoechogenic thickening was attributable to
main bile duct hypervascularization ([Fig. 3]). Transduodenal endoscopic ultrasound revealed several dilated vessels compressing
the lower bile duct ([Video 1]). Endoscopic management of such stenoses is associated with a very high risk of
hemorrhage [4], especially in patients who have undergone sphincterotomy. We placed a portosystemic
shunt in this patient.
Fig. 1 Computed tomographic scan and magnetic resonance imaging of biliary tract.
Fig. 2 Bile duct thickening.
Fig. 3 Bile duct hypervascularization.
Video 1 An unexpected diagnosis when endoscopic ultrasound was used to explore a case of
undetermined biliary stenosis.
Endoscopy_UCTN_Code_CCL_1AZ_2AN
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